NICU Nutrition Pathway

Transcription

1 NICU Nutrition Pathway Safely Infusing NICU TPN Starter and Custom TPN April17 th 2018 Pharmacists: Paul Kasprzak RPH BCPS Kelly Kopec PharmD

2 Major Practice Changes in the Preparation and Administration of Custom TPN and TPN Starter 1. New TPN Starter Protocol Day of life one only, infants 1500 grams and less Concentrated Starter TPN + Lipid + D5W are co-infused Consistently provides goal protein (3gm/kg/day) 2. Practice of Concentrating Custom TPN Volume of enteral feeding and volume of continuous infusions are subtracted from total daily fluid allowance to equal volume of TPN prepared Optimizes parenteral nutrition provided to the neonate

3 New NICU TPN Starter Protocol Indication TPN Starter Protocol is indicated for neonates less than or equal to 1500 grams on day one of life only Infants greater than 1500 grams will receive plain D10W +/- Calcium if IV fluids are needed. Reason for change To consistently provide goal protein (3gm/kg/day) Caution the new TPN Starter bag is highly concentrated: Infusion rate of TPN Starter must never be increased from originally prescribed rate of 50 ml/kg/day (2.1 ml/kg/hr) Must co-infuse with IV Fat emulsion and Dextrose infusion

4 New NICU TPN Starter Protocol (Indicated on Day of life 1 for neonates < or = 1500 grams) TPN Starter Protocol consists of three orders that are co-infused. 1. TPN Starter bag (Dextrose 10% / Trophamine 6% / Calcium Gluconate 2.33 meq / Heparin 125 unit/250 ml) Rate: 2.1 ml/kg/hr (50mL/kg/day) This is a highly concentrated starter bag. The infusion rate must NOT exceed 2.1 ml/kg/hr (50mL/kg/day). 2. Fat emulsion 20% Rate: 0.21 ml/kg/hr (1gm/kg/day = 5mL/kg/day) 3. Dextrose 5% Rate: Infuse at rate to achieve total fluid allowance goal

5 Ordering the NICU TPN Starter Protocol Provider will order in powerchart via the NICU TPN Starter PowerPlan AHC The appropriate dose and infusion rate of the TPN Starter and fat emulsion will auto populate Patient s weight must be entered in care connection by the nurse or in the orders by the physician for the TPN starter and fat emulsion order fields to auto populate 1. Dextrose 10 % / Trophamine 6% / Calcium Gluconate 2.33 meq/ Heparin 125 unit/250 ml Rate: 2.1 ml/kg/hr 2. Fat emulsion 20%, Dose: 5mL/kg, Rate: 0.21mL/kg/hr 3. Dextrose 5%, Dose field empty, Comment on order: Infuse at rate to achieve total fluid allowance goal Infusion rate of D5W must be calculated & entered by provider

6 Calculation of Infusion Rate for D5W Provider, Rn and Pharmacist must ensure correct infusion rate for TPN Starter, Fat emulsion, and Dextrose 5% (D5W). Dextrose 5% infusion rate = Total daily fluid allowance TPN Starter Fats IV continuous infusions Calculation to determine rate of Dextrose 5% to be co-infused with Starter TPN: Total fluid allowance ml/kg/day divided by 24 = ml/hr Starter bag: 2.1mL/kg/hr x kg = (-) ml/hr Fat emulsion 20%: 0.21mL/kg/hr x kg = (-) ml/hr Total infusions (ex:art line, sedation, pressors in ml/hr) (-) ml/hr Rate of Dextrose 5% (D5W) (=) ml/hr

7 Question 1 Question: What is the infusion rate of D5W for the following patient on TPN starter protocol? Weight 0.8 kg. TF 90mL/kg/day. Art line 0.5mL/hr, Fentanyl drip 0.23mL/hr. Total fluid allowance ml/kg/d x kg 24hr = ml/hr Starter bag: 2.1 ml/kg/hr x kg = (-) ml/hr Fat emulsion 20%: 0.21 ml/kg/hr x kg = (-) ml/hr Infusions (Art line ml/hr + Fent ml/hr)= (-) ml/hr Rate of Dextrose 5% (D5W) (=) ml/hr A) 1 ml/hr B) 0.6 ml/hr C) 0.4 ml/hr D) 0.2 ml/hr

8 Question 1 Correct: C) 0.4 ml/hr Question: What is the infusion rate of D5W for the following patient on TPN starter protocol? Weight 0.8 kg. TF 90mL/kg/day. Art line 0.5mL/hr, Fentanyl drip 0.23mL/hr. Total fluid allowance 90 ml/kg/d x 0.8 kg 24hr = 3 ml/hr Starter bag: 2.1 ml/kg/hr x 0.8 kg = (-) 1.7 ml/hr Fat emulsion 20%: 0.21mL/kg/hr x 0.8 kg = (-) 0.17 ml/hr Infusions (Art line 0.5 ml/hr + Fent 0.23 ml/hr): (-) 0.73 ml/hr Rate of Dextrose 5% (D5W) (=) 0.4 ml/hr A) 1 ml/hr B) 0.6 ml/hr C) 0.4 ml/hr D) 0.2 ml/hr

9 Question 2 Question: The provider places an order to increase total fluids to 110 ml/kg/day. What is the new rate of the TPN Starter? Weight 0.8 kg. TF 110mL/kg/day. Art line 0.5mL/hr, Fentanyl drip 0.23mL/hr. Total fluid allowance ml/kg/d x kg 24hr = ml/hr Starter bag: 2.1 ml/kg/hr x kg = (-) ml/hr Fat emulsion 20%: 0.21 ml/kg/hr x kg = (-) ml/hr Infusions (Art line ml/hr + Fent ml/hr)= (-) ml/hr Volume of Dextrose 5% (D5W) (=) ml/hr A) 3.7 ml/hr B) 2.4 ml/hr C) 3 ml/hr D) 1.7 ml/hr

10 Question 2 Correct answer: D) 1.7 ml/hr The rate of the TPN Starter must never increase. It will never infuse faster than 2.1mL/kg/hr. The rate of D5W will increase to achieve the new total fluid goal.. Question: The provider places an order to increase total fluid to 110 ml/kg/day. What is the new rate of the TPN Starter? Weight 0.8 kg. TF 110mL/kg/day. Art line 0.5mL/hr, Fentanyl drip 0.23mL/hr. Total fluid allowance 110 ml/kg/d x 0.8 kg 24hr = 3.7 ml/hr Starter bag: 2.1 ml/kg/hr x 0.8 kg = (-) 1.7 ml/hr Fat emulsion 20%: 0.21 ml/kg/hr x 0.8 kg = (-) 0.17 ml/hr Infusions (Art line 0.5 ml/hr + Fent 0.23 ml/hr): (-) 0.73 ml/hr Rate of Dextrose 5% (D5W) (=) 1.1 ml/hr A) 3.7 ml/hr B) 2.4 ml/hr C) 3 ml/hr D) 1.7 ml/hr

11 Concentrating TPN Concentrating the TPN is the practice of subtracting the volume of enteral feeding, continuous infusions and fat emulsion from the total daily fluid allowance to calculate the volume of the TPN. This practice will be necessary in order to accurately follow the new feeding guideline in the NICU nutrition pathway.

12 Concentrating TPN - Calculation of Custom TPN Volume Custom TPN is ordered daily on the Neonatal TPN order form and is tailored to the individual needs of each patient. The prepared volume and rate of infusion of the custom TPN will be determined by the patients total fluid intake for 24 hrs minus enteral feedings, the lipid infusion and any other continuous infusions. IMPORTANT: The rate of the custom TPN must NEVER exceed the originally prescribed rate. If needed, dextrose (D5,D10) will be coinfused to achieve the total fluid goal.

13 Custom TPN Calculations Total Daily Fluid Intake ml/kg/day x kg = ml 24h Non TPN IV Infusions + + (-) ml /24hs Enteral RX: at ml q hrs (-) ml Parenteral Nutrition Allowance (=) ml. Fat Emulsion 20% gm/kg x kg = gm x 5 ml/gm (=) ml to infuse over 24 hr = ml/hr TPN Volume/24 hours (parenteral nutrition allowance intralipid volume) ml to infuse over 24 hrs = ml/hr

14 Calculating Custom TPN Patient Case #1 Using the following patient case, a Custom TPN volume and rate will be calculated Patient BC Weight 0.9 kg Daily total fluid intake 140 ml/kg/day Intralipids are 2 gm/kg/day Feeding is donor breast milk at 3 ml Q 3hrs Dopamine drip infusing at 0.2 ml/hr (3 mcg/kg/min)

15 Calculations wt: 0.9kg, TF: 140 ml/kg/day, fats: 2gm/kg/day, enteral feed: 3ml q3h, dopamine 0.2ml/hr Total Daily Fluid Intake 140 ml/kg/day x 0.9 kg = 126 ml 24h Non TPN IV Infusions dopamine 4.8 ml + + (-) 4.8 ml /24hs Enteral RX: donor breast milk at 3 ml q 3 hrs (-) 24 ml 126 ml 4.8ml 24 ml = 97.2 ml PNA Parenteral Nutrition Allowance (=) 97.2 ml Fat Emulsion 20% 2 gm/kg x 0.9 kg = 1.8 gm x 5 ml/gm (=) 9 ml to infuse over 24 hr = 0.38 ml/hr 97.2 ml PNA 9 ml lipids = 88.2 ml TPN volume TPN Volume/24 hours (parenteral nutrition allowance intralipid volume) 88.2 ml to infuse over 24 hrs = 3.7 ml/hr

16 Calculating Custom TPN Patient Case #1 The patient from case # 2 has become hypotensive. The dopamine drip has increased from 0.2 ml/hr to 0.4 ml/hr. The patient has also been made NPO How will the change in fluids be managed when a custom TPN is infusing? Patient BC Weight 0.9 kg Daily total fluid intake 140 ml/kg/day Intralipids are 2 gm/kg/day Feeding is donor breast milk at 3 ml Q 3hrs Patient is now NPO Dopamine Drip infusing at 0.2 ml/hr (3 mcg/kg/min) Dopamine drip 0.4 ml/hr

17 Calculating Custom TPN Patient Case #1 If the patient is made NPO, the loss in fluids per day is 24 ml or 1 ml/hr The increase in dopamine provides the patient an additional 0.2 ml/hr An additional fluid must be piggybacked into the TPN at 0.8 ml/hr to maintain a total fluids per day of 140 ml/kg The Custom TPN rate cannot be increased to add additional fluids The fluid can be dextrose 5% or 10% depending on the patients glucose requirements Total fluids = 140 ml x 0.9 kg = 126 ml 126 ml dopamine 9.6 ml/24hrs intralipid 9 ml/24hrs TPN of 88.2 ml/24 hrs = 19.2ml 19.2 ml divided by 24 hrs = 0.8 ml/hr additional fluid required Total fluids = 140 ml x 0.9 kg = 126 ml divided by 24 = 5.3 ml/hr 5.3 ml/hr dopamine 0.4 ml/hr intralipid 0.38 ml/hr TPN of 3.7 ml/hr = = 0.8 ml/hr additional fluid required

18 Calculations wt: 0.9kg, TF: 140 ml/kg/day, fats: 2gm/kg/day, enteral feed: now npo, dopamine increased to 0.4ml/hr The Custom TPN rate cannot be increased to add additional fluids The additional fluid will be dextrose (5%, 10%, or possibly higher depending on the patients glucose requirements). Total fluid allowance 140 ml/kg/hr x 0.9kg 24hr = 5.25 ml/hr Custom TPN: 3.7 ml/hr (TPN rate will NOT change) = (-) 3.7 ml/hr Fat emulsion 20%: = 2gm/0.9kg x 5ml/gm = 9ml 24hr = (-) 0.38 ml/hr Dopamine increased to 0.4ml/hr (-) 0.4 ml/hr Enteral feeds: NPO 0 ml/hr Rate of additional fluid (D5W or D10W) (=) 0.77 ml/hr = 0.8ml/hr

19 Conclusion Take home message The infusion rate of the TPN starter or the custom TPN will never exceed the originally prescribed hourly rate If additional fluids are needed, a dextrose infusion will be co-infused with the custom TPN or TPN starter to achieve the total fluid allowance goal.